Inside an Operating Theatre of the 1900s: A Review of Cinemax’s “The Knick”

This post includes a review of Cinemax’s The Knick and contains minor spoilers.

On arriving to Bellevue Hospital in New York in the 1880s, American surgeon Robert Morris (1857-1945) commented on the new surgical operating rooms at the institution:

[T]he operating room was similar to that of other large general hospitals. The set-up consisted of a plain wooden table to carry instruments, lint or oakum dressing, unbleached muslin bandages (we had no absorbent gauze or cotton), and a large tin basin of tap water. Sometimes plaster of paris and other splint outfit was added.[1]

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Dr. William Williams Keen conducts a surgical clinic in the Jefferson Medical College Hospital amphitheater, c.1890s.
Archives & Special Collections, Thomas Jefferson University, Philadelphia.

I’m utterly fascinated with the surgical operating theater and how it evolved from a simple room with minor equipment to a packed theatre stage, and eventually to the sterile and spacious environment of modern operating rooms. The transformation of the operating theatre mirrors many tremendous advancements in the surgery during the twentieth century, as surgeons became more skilled and innovative as they mastered complicated and dangerous procedures. It’s no surprise then that I was completely riveted by Cinemax’s new television series, The Knick, directed by Steven Soderbergh, written  by Jack Amiel and Michael Begler, and starting Clive Owen.

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The show takes place in turn-of-the-century New York City, with Owen playing the anti-hero Dr. John Thackray, surgeon at the Knickerbocker Hospital. The pilot episode, “Method and Madness” brilliantly captures the dual nature of medicine: we see Thackray begging his nurse (Eve Hewson) to inject him with 22cc of cocaine, and a short time later, watch him order her to prepare a 2% solution as an innovative spinal anaesthetic to inject a patient on the operating table.

The show’s opening scene in the operating room is, in a word, gory, illustrating the difficulty of procedures that are considered as routine today. Bareknuckle surgery. 100 seconds to perform a caesarean section on a patient with haemorrhage in the womb. Brass hand cranks for suction. White aprons and rolled-up sleeves of street clothes. The rubber apron of Dr. Jules Christiansen (Matt Frewer), which could barely camouflage the surgeon’s hopelessness and despair over 12 unsuccessful caesarean operations. When the patient and baby die on the operating table, Christiansen turns to his audience and reminds them that surgery is about advancement: “It seems…it seems we are still lacking. I hope, if nothing else…this has been instructive for you all.”

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During the early 19th century, operative surgery was limited to breakages, fractures, and amputations. Experimental operations to save the life of a patient were incredibly painful, gruesome, and, in many instances, unsuccessful. Two major advances during the mid-19th century would establish a foundation for surgeons to innovate new life-saving operations with greater confidence: the discovery of anaesthetics and the introduction of antiseptics. Analgesics were always made use of in medicine, as medical practitioners were aware of certain natural substances contained properties for relieving pain, such as opium or alcohol. During the 1790s, experiments of the effects of inhaling various gases and vapours first initiated the possibility pain relief could be achieved by inhalation of some suitable vapour or gas. Humphrey Davy (1778-1829) experimented with nitrous oxide (laughing gas), but other medical practitioners did not pay attention to his developments. The 1840s introduced ether as a more satisfactory anaesthetic, though chloroform anaesthesia became widespread as well after 1847 when James Young Simpson (1811-1870) first used it to relieve a patient’s difficult childbirth pains.

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Dr. William Halstead is the inspiration for Clive Owen's character.

However, post-operative sepsis infection accounted for the majority patient deaths after major surgery. Antiseptics and antiseptic surgical methods became widespread with Joseph Lister’s (1828-1912) introduction of carbolic acid (phenol) as a method for eliminating bacteria on skin and on surface objects. The development of anaesthetics and antiseptics spearheaded the notion of a painless surgical operation. In the 1870s, towns with 10,000 residents had only 100 hospitals within their limits or nearby; by 1910, the number of hospitals increased to over 4,000, as new, innovative surgical procedures were became more successful.[2]

Even with anaesthetics and antiseptics, surgery was an incredible gruesome practice. Operations were performed either in patient wards, a small operating room, or in front of hundreds of students in the ordinary lecture theatre. We see this in The Knick, which surely benefited from the medical, historical and technical advice of Dr. Stanley Burns and the Burns Archive.

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The scenes in the operating theatre appear to jump out of the incredible photographic collections housed at the Burns Archives. I found it difficult to get emotionally connected to characters, though the pilot episode did set up a solid foundation to explore their developments as well as the broader cultural strokes of America in the 1900s. Midwifery and “Stretcher Men;” divisions of the rich and poor; hospital administration; and of course, new technological developments like electricity being fitted in the Knick as it undergoes renovation. Dr. Algernon Edwards (Andre Holland) the “Negro” surgeon, gives us an interesting insight into America racial tensions, but I was more captivated with the scenes of the squalor and poverty of immigrants. The New York Public Health Board’s inspections of tuberculosis cases and their forced removal of sick persons, for instance, shows us how medicine was enforced in the legislative level, as laws outlined demands to enforce structural changes in housing to eradicate breeding grounds for disease. These scenes are a reminder of the terrifying cloud of disease and death.

You can watch the first episode here: http://youtu.be/ItBAXOEE8Vk

 

NOTES

[1] Quoted in Roy Porter, Greatest Benefit to Mankind: A Medical History of Humanity (New York: W.W. Norton & Company, 1997), 374.

[2] Morris J. Vogel, “Managing Medicine: Creating a Profession of Hospital Administration in the United States, 1895-1915,” in Lindsay Granshaw and Roy Porter (Eds.), The Hospital in History (New York: Routledge, 1989).

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Surgeons & Surgical Kits

There’s always a scene in any movie or television show depicting a surgical operation: a nurse or assistant clad in scrubs, enters the room pushing a cart. On the cart lies several delicate instruments, their hard steel glistening under the harsh lights of the theatre. None of the instruments touch each other, and they are placed in a carefully organized order.

Then we see the scene after the operation: the once pristine instruments stained with the bright red of blood, and discarded into a bowl. They have fulfilled their purposes, the dangers embodied in their construction has diminished and they are to retire until they are called for again.

I love those scenes. The instruments play as much of a role in surgical operations as the nurse, the lights, the antiseptics anesthetics and of course, the surgeon. But without the instruments there really is no operation. Without the instruments is a surgeon even a surgeon?

The 10th century Arabic scholar and physician, Abu al-Quasim ibn al-Abbas al-Zahrawi (936-1013) introduced many notable surgical instruments in his eponymous Kitab al-Tasrif ( Method of Medicine), a thirty volume encyclopedia on the anatomy and practise of medicine. Al-Zahrawi, also known by his Latinized name Albucasis, details over 200 instruments, many of which he devised himself, combining ideas from ancient Greek and Roman physicians with his own observations and experiences as a surgeon.

A replica of Roman surgical instruments in a cloth roll, AD50. 13 instruments made of brass and steel. (The Old Operating Theatre Museum)
A replica of Roman surgical instruments in a cloth roll, AD50. 13 instruments made of brass and steel. (The Old Operating Theatre Museum)

Al-Zahrawi stressed a skilled surgeon would not only know the uses and benefits of numerous types of instruments, but will apply the knowledge to make sure an instrument was used properly and carefully to prevent excessive pain to the patient. Other medieval surgeons also stressed the importance of instruments–the surgeon’s kit–as an essential part of the surgeon’s practice.

Before the operating theatre had instruments nicely laid out on a cart, surgeons often carried their own instruments in a box or bag, taking with them as they attended to patients. Some were of simple designs, while others were more elaborate, with ivory, gold, or silver detailing.

An ivory surgical presentation set, c.1868. It contains  a full complement of scalpels, bistouries, needle threaders and tenaculum hooks.  The lid compartment contains two scissors, one pair of scissor handled and two hand forceps. The lower tray contains a crosshatched ivory metacarpal saw, a director, two silver tracheotomy tubes, a crosshatched ivory and silver trocar and a pair of bone forceps. This was the Governor's Prize at Middlesex Hospital and awarded to Mr. Robert Harry Lords. (Phisick Medical Antiques)
An ivory surgical presentation set, c.1868. It contains a full complement of scalpels, bistouries, needle threaders and tenaculum hooks. The lid compartment contains two scissors, one pair of scissor handled and two hand forceps. The lower tray contains a crosshatched ivory metacarpal saw, a director, two silver tracheotomy tubes, a crosshatched ivory and silver trocar and a pair of bone forceps.
This was the Governor’s Prize at Middlesex Hospital and awarded to Mr. Robert Harry Lords. (Phisick Medical Antiques)

These kits consisted of knives, razors, and lancet for making incisions; cattery irons grasping tools, probes, suture scissors, saws, needles, cannulae, pads, bandages, and in some instances, even tools for trepanation. Some kits also contained analgesics such as opium or hashish as pain relievers, or plasters for treating wounds.

A 19th century 14-piece surgical instrument kit (Barcelona)
A 19th century 14-piece surgical instrument kit (Barcelona)
A 19th century French surgical leather kit with knife and needle, artery forceps, curved scissors, curette, trocar, director, blunt needle, thermometer, caustic stick holder,  toothed forceps and two plain forceps. (Phisick Medical Antiques)
A 19th century French surgical leather kit with knife and needle, artery forceps, curved scissors, curette, trocar, director, blunt needle, thermometer, caustic stick holder, toothed forceps and two plain forceps. (Phisick Medical Antiques)

Pre-anesthetic surgery was crude, gruesome, and horrifying. Operations were limited to amputations, suturing, and bone-setting. And because it was preferable patients remained awake during the operation (as it was easier to deduct whether there was serious danger), speed was a crucial factor for ensuring a higher degree of success. Instruments were used over and over, frequently without being cleaned, and without being disinfected–antiseptics wouldn’t arrive until the second half of the nineteenth century.

Five surgeons participating in the amputation of a man's leg while another oversees them.  Coloured Aquatint by Thomas Rowlandson, 1793.
Five surgeons participating in the amputation of a man’s leg while another oversees them.
Coloured Aquatint by Thomas Rowlandson, 1793.

The Artificial Tympanum

Perforation of the eardrum (tympanic membrane or tympanum) is a very common injury to the ear, often resulting from ear infection, trauma (damn those Q-tips!), loud noise, or blockages in the Eustachian tubes. Most cases the damage is minor and the drum heals quickly on its own, but other cases bring about hearing loss, and consequently, the rupture requires intervention to correct the damage.

The German physician Marcus Banzer (1592-1664) provided the first recorded account of correcting perforation of the tympanic membrane. In 1640, he published Disputatio de auditione laesa (Dissertation on Deafness) in which he describes the use of a tube made of elk hoof and connected to a pig’s bladder, to be used as a prosthetic eardrum. This construction replaced the rupture and aimed to protect the middle parts by preventing the funneling of external air, leading to further damage. This way, the eardrum could resume its function: air on both sides of the drum regulating sound.*

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An example of the artificial eardrum, from Life Magazine 5 December 1949

By the nineteenth century, however, there were no effective surgical treatments for perforation of the eardrum or the hearing loss that accompanied it. But there were many, many remedies recommended by physicians and aural surgeons, all applying the idea that the rupture needed to be closed somehow, but still allow sound to funnel through the ear drum. Some measures included: India rubber, lint, tin or silver foil, the vitelline membrane of an egg. Adhesion of the apparatus to the ear were used with: saliva, water, petroleum jelly, or glycerine.

Oh, that’s all, you say? Nope—how about cotton-wool inserted into the ear? Or onions? Pieces of fat bacon toasted over a candle then inserted into the ear along with some wax drippings? Pour some oil into your ear! Or when all else fails, just create your own homemade artificial eardrum with elk’s claw, pig’s bladder, fish bone, gold beater’s skin, or even some court plaster.[1]

Here’s when it gets interesting. In 1841, the aural surgeon James Yearlsey—who had just enough of quackery in aural surgery, by the way, and was advocating medical and surgical reform—became acquainted with the idea of constructing a surgical apparatus to treat perforation of the ear drum, when a patient from New York came to London for a consultation. Seven years later, he published a paper in The Lancet describing his new artificial tympanum made with cotton balls applied to the end of extraction cords.

However, whatever revolutionary sentiments Yearsley hoped with his innovation, were squashed by Joseph Toynbee (1815-1866), the charming and popular aural surgeon who once worked with Richard Owen at the Hunterian Museum. Toynbee is also father to the famous philosopher and economist Arnold Toynbee (1852-1883).

L0011028 Joseph Toynbee

Toynbee presented a paper on his artificial tympanum—making no reference to Toynbee—at the 1850 Annual Meeting of the Provincial Medical Association. His innovation was composed of gutta percha (natural latex made from South Asian trees of the same name—a very popular 19C material that eventually collapsed from overuse)  or vulcanized rubber, attached to a silver wire stem about 3cm. Toynbee followed his presentation with a paper, “On the Use of an Artificial tympanic Membrane,” published in 1853, which earned him a medal from the Society of Arts. The guidewire was used to install the device into the tympanic cavity, adhering the rupture and still allowing sound to funnel through the fine tube.

As you can imagine, Yearsley was outraged. Aural surgery during the 1850s was overwhelmed with priority disagreements between Yearsley and Toynbee, and many other enthusiastic aural surgeons chimed in their two cents on the efficacy of each of these new devices. Further surgical advancements would later demonstrate that artificial tympanic membranes have little value, for over time, the eardrum just heals itself naturally, or else grafts are recommended in cases of serious ruptures.

 

* Many thanks to Dr. Albert Murdy for the clarification.


[1] Eugene A. Chu and Robert K. Jackler, “The Artificial Tympanic Membrane (1840-1910): From Brilliant Innovation to Quack Device,” Otology & Neurotology 24 (2003): 507-518.

Medieval Surgery: Abulcasis

I was watching World Without End and came across this scene in which a female medical practitioner explains the value and beauty of a surgical textbook she purchased:

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I don’t recognize the book–does anyone know what it is?

On the left page, there’s a man fighting Death. The right page is the Zodiac Man, an explanation of how the signs of the zodiac govern different aspects of the body–it was often used by medieval physicians to decide when bloodletting was more favorable and what body parts to avoid for surgery in conjunction to the alignment of the stars.

Medieval surgery is interesting in that it is the one medical occupation besides physician’s medicine that was taught at the university, particularly in southern Italy. However, most surgeons would not have been university educated, since they would have learned primarily through apprenticeships. They dealt primarily with every day injuries such as broken limbs, sprains, dislocations burns, and so on. At the fringes of the surgeon’s trade were those practitioners (often unlicensed) who specialized in particular operations like bone-setting, tooth-pulling, couching cataracts and so forth.

However, it did bring to mind the how Arabic treatises were adopted and translated into Latin. Between the 6th-11th centuries, medical handbooks had little or nothing to say about surgery and for the most part, surgery was not separated from medical practice. After 12th century, books on surgery began to emerge and evolve as a distinct form of medical writing. As with physicians’ medicine, much was learnt through Arab texts, particularly the work of Abu al-Qasim ibn al-Abbas Al-Zahrawi (936–1013), known by his Latanized name Abulcasis.

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Considered the greatest medieval surgeon from the Arab-Islamic world, he has even been named the father of modern surgery. His greatest work is the Kitab al-Tasrif [Method of Medicine], 30-volume encyclopedia that described pioneering surgical procedures and instruments—over 200 hundred instruments are detailed in the book! Not only did Abulcasis devise many of these instruments himself, but many are still in use today.

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The impact of Abulcasis’ book was enormous once it was translated into Western Latin by Gerard of Cremona in 12th century Spain, who also illustrated the book. The al-Tasrif became a standard reference for both doctors and surgeons as it was translated into Latin five times.

Two pages from an incunabulum of the 30th section of Al-Tasrif as translated to Latin in the 12th century by Gerard of Cremona.
Two pages from an incunabulum of the 30th section of Al-Tasrif as translated to Latin in the 12th century by Gerard of Cremona.

With works like the al-Tasrif, there soon existed a body of specialized knowledge that was preserved in learned sources—in authoritative textbooks; surgery becomes a literate discipline. Eminent surgeons then insisted that learned medicine, as well as a good eye, a steady hand, and a sharp blade could make an excellent surgeon

Monday Series: Inquest into a Surgical Procedure IV

As per guidelines for coroner’s inquests, the jury was to view the body and judge their verdict on their observations as well as on the witness depositions and postmortem report. This raises specific questions about the value of medical witnessing, which Thomas Wakley argued was essential for a proper investigation. Yet the cause of death was only one aspect of the case—the other being, of course, whether blame should be assigned to the practitioners involved in the case. Wakley complained that although Hall died on Saturday morning, no notice of his death was sent by Dr. Turnbull or Mr. Lyon to the summoning officers of the district. Inspector Sampson Campbell of the East Division of Police even testified that he did not hear of the death until Sunday evening, after being told by a Mr. Bye (possibly Hall’s employer) that a death had occurred in Turnbull’s practice of rather suspicious circumstance sand he requested Campbell to investigate.

At the inquest, Wakley asked Turnbull and Lyon to provide some explanation of their conduct; Turnbull admitted the death occurred at his residence, but denied blame, remarking that he wasn’t aware of the death until three hours after it happened; Lyon, on the other hand, argued that Turnbull was perfectly aware of the circumstances and was in the next room attending to gentlemen, when Hall expired. The case also raised confusion, due to conflicting witness reports claiming that it was Hall himself who set the fourth and final charge instead of Lyon (who gave the first three) thus being responsibility for his own death.

Continue reading Monday Series: Inquest into a Surgical Procedure IV